Contact Dorsey & Associates | Insurance Agency

Pre-Application for Automobile’s Insurance

Name of proposed insured:

Date of birth:

Address:

Email Address:

Do you own your home/mobile home, Rent, or live with parents?

Driver’s license #:

Social security(s) #:

Martial status (single, married, divorced, widowed):

Daytime phone #:

Evening phone #:

Name of additional insured:

Date of birth OF ADDITIONAL INSURED:

Driver’s license OF ADDITIONAL INSURED#:

Have you had continuous auto insurance for the past 6 months?

Current insurance company name:

Year, make and model of car(s):

VIN#(S):

Is the car driven for RIDESHARING OR DELIVERIES (UBER, LYFT, DOORDASH, ETC ?:

How much insurance coverage do you currently have? (15/30, 25/50, 50/100, 100/300):

How much Property Damage & Medical Benefits:

Do you have full tort or limited tort?:

Free Text

ADDITIONAL INSURED INFORMATION

# of accidents or major or minor violations for past 5 YEARS?:

Year, make and model of car(s):

VIN#(S):

List all other drivers in the household that do not have other auto insurance:

List all other drivers in the household that do not have other auto insurance:

Name:

DOB:

SS:

DL#:

Name:

DOB:

SS:

DL#:

6641 Germantown Ave.

Philadelphia, PA 19119

Phone: 215-713-2886 | Fax: 866-713-1173